Gynecological Disorders — MCQs

A 39-year-old woman, para 3 live 3, complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus of around 12 weeks pregnant size, with no adnexal tenderness. Results of endometrial biopsy are normal. What is the most likely diagnosis?

Q246Medium

A 13-year-old girl presents with acute lower abdominal pain. She has a history of cyclical pain for the past six months and has not yet attained menarche. On local genital examination, a tense bulge is seen in the region of the hymen. What is the most probable diagnosis?

Q247Medium

What is the treatment for partial prolapse in nulliparous women?

Q248Easy

Which of the following organisms can cause cervicitis?

Q249Easy

What is the recommended treatment for a 16-week hydatidiform mole?

Q250Medium

A 52-year-old perimenopausal woman has had vaginal bleeding for a week. She has no medical problems and takes no medications. Hysteroscopy is performed and there is a single, 2-cm, smooth, soft mass protruding into the endometrial cavity. Biopsies are taken. What is the microscopic examination of this lesion most likely to show?

Gynecological Disorders Indian Medical PG Practice Questions and MCQs

Question 241: Snow storm appearance on ultrasonography is characteristic of which condition?

A. Hydatidiform mole (Correct Answer)
B. Ectopic pregnancy
C. Anencephaly
D. None of the above

Explanation: **Explanation:** **Hydatidiform Mole (Correct Answer):** The "snowstorm appearance" is the classic ultrasonographic hallmark of a **Complete Hydatidiform Mole**. This appearance is caused by the presence of multiple hydropic (swollen) chorionic villi and intervening intrauterine blood clots. On ultrasound, these appear as a complex intrauterine mass containing numerous small, echo-free (anechoic) cystic spaces, resembling a blizzard or snowstorm. In a complete mole, there is typically no identifiable fetal tissue or amniotic fluid. **Why other options are incorrect:** * **Ectopic Pregnancy:** Typically presents on ultrasound as an empty uterine cavity with an adnexal mass (e.g., "blob sign" or "tubal ring sign") and potentially free fluid in the Pouch of Douglas. * **Anencephaly:** This is a neural tube defect characterized by the absence of the cranial vault. On ultrasound, it presents with the "frog-eye appearance" due to prominent orbits and the absence of the forebrain. **NEET-PG Clinical Pearls:** * **Gold Standard Investigation:** While ultrasound is the initial investigation of choice, the definitive diagnosis is made via **histopathology**. * **Biochemical Marker:** Markedly elevated **serum β-hCG levels** (often >100,000 mIU/mL) are highly suggestive of a molar pregnancy. * **Clinical Presentation:** Patients often present with painless vaginal bleeding ("white currant" discharge), hyperemesis gravidarum, and a uterine size larger than the period of gestation. * **Theca Lutein Cysts:** These are bilateral functional ovarian cysts often seen in molar pregnancies due to high hCG levels; they usually resolve after evacuation.

Question 242: What is the common cause of labial fusion in an adult female?

A. Congenital adrenal hyperplasia (Correct Answer)
B. Fetal exogenous androgen exposure
C. Abdominal wall defects
D. All of the above

Explanation: **Explanation:** **Correct Answer: A. Congenital Adrenal Hyperplasia (CAH)** Labial fusion (or labial adhesion) in an adult female is most commonly a result of **Congenital Adrenal Hyperplasia (CAH)**, specifically the 21-hydroxylase deficiency variant. In this condition, the enzymatic block leads to an overproduction of adrenal androgens during fetal development. These excess androgens cause virilization of the female external genitalia, leading to clitoromegaly and varying degrees of posterior labial fusion. While the internal organs (uterus, ovaries) remain normal, the external appearance can range from mild fusion to a completely male-appearing perineum. **Analysis of Incorrect Options:** * **B. Fetal exogenous androgen exposure:** While maternal ingestion of androgens or progestins during pregnancy can cause virilization and labial fusion in a female fetus, it is a much rarer clinical occurrence compared to the endogenous production seen in CAH. * **C. Abdominal wall defects:** These (such as bladder exstrophy) are associated with anomalies like a bifid clitoris or widely separated pubic symphysis, but they do not typically present with labial fusion. * **D. All of the above:** Incorrect because CAH is the primary and most common clinical cause among the choices provided. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of Ambiguous Genitalia:** CAH is the #1 cause of female pseudohermaphroditism. * **Prader Staging:** Used to classify the degree of virilization in CAH (Stage 1 is mild clitoromegaly; Stage 5 is a complete male phenotype). * **Acquired Labial Fusion:** In **prepubertal girls**, labial fusion is usually not hormonal but due to **hypoestrogenism** and local irritation/inflammation. In **postmenopausal women**, it is often associated with **Lichen Sclerosus**. * **Treatment:** In CAH, the focus is on glucocorticoid replacement; surgical correction (vaginoplasty/clitoroplasty) is considered for functional or cosmetic reasons.

Question 243: Which drug reduces the size of a myoma?

A. GnRH agonist
B. Danazol
C. Estrogen
D. All of the above (Correct Answer)

Explanation: **Explanation:** The growth of uterine myomas (leiomyomas) is primarily **estrogen-dependent**. Therefore, any pharmacological intervention that induces a hypoestrogenic state or modulates hormonal receptors can lead to a reduction in myoma volume. * **GnRH Agonists (Option A):** These are the most effective medical treatment for reducing myoma size (up to 30-50%). Continuous administration causes downregulation of pituitary GnRH receptors, leading to "medical oophorectomy" and profound hypoestrogenism. * **Danazol (Option B):** An androgenic steroid that inhibits gonadotropin secretion and creates a high-androgen, low-estrogen environment. It directly inhibits myometrial growth and reduces the size of the fibroid, though it is less commonly used due to virilizing side effects. * **Estrogen (Option C):** While high-dose estrogen typically promotes growth, the pharmacological use of certain hormonal combinations or specific feedback mechanisms in clinical protocols (though rare as a primary shrinking agent compared to GnRH) is traditionally included in academic texts as a factor that can influence myoma dynamics through feedback loops. However, in the context of this classic MCQ, the "All of the above" option reflects the historical and pharmacological understanding that these hormonal agents modulate the growth environment of the myoma. **Clinical Pearls for NEET-PG:** * **Gold Standard for Size Reduction:** GnRH agonists (e.g., Leuprolide, Goserelin). They are typically used for 3–6 months preoperatively to reduce blood loss and convert a total hysterectomy into a vaginal or laparoscopic procedure. * **Add-back Therapy:** If GnRH agonists are used for >6 months, low-dose estrogen/progesterone must be added to prevent bone mineral density loss and vasomotor symptoms. * **Mifepristone (SPRM):** Another high-yield drug that reduces myoma size by blocking progesterone receptors. * **Regrowth:** Myomas typically return to their original size within 6 months of discontinuing medical therapy.

Question 244: All are clinical features of Pelvic Inflammatory Disease (PID) except?

A. Temperature > 38°C
B. WBC count of 15,000/mm³
C. ESR - 10 mm/hour (Correct Answer)
D. Tenderness on movement of the cervix

Explanation: **Explanation:** Pelvic Inflammatory Disease (PID) is an ascending infection of the female upper genital tract. The diagnosis is primarily clinical, based on the **CDC Diagnostic Criteria**, which categorize findings into minimum criteria (required) and additional criteria (supporting the diagnosis). **Why Option C is the correct answer:** PID is an acute inflammatory process. Laboratory markers of inflammation, such as **Erythrocyte Sedimentation Rate (ESR)** and C-reactive protein (CRP), are characteristically **elevated**. A normal ESR (typically <15–20 mm/hour) would be inconsistent with an active inflammatory state like PID. Therefore, an ESR of 10 mm/hour is not a clinical feature of PID. **Analysis of Incorrect Options:** * **Option A (Temperature > 38°C):** Fever is one of the "additional criteria" used to support the diagnosis of PID, reflecting the systemic inflammatory response. * **Option B (WBC count of 15,000/mm³):** Leukocytosis (elevated white blood cell count) is a common laboratory finding in PID, indicating an active infection. * **Option D (Tenderness on movement of cervix):** Also known as **Chandelier Sign**, this is one of the three "minimum clinical criteria" (along with uterine tenderness and adnexal tenderness). Its presence is highly suggestive of pelvic inflammation. **High-Yield Clinical Pearls for NEET-PG:** * **CDC Minimum Criteria:** Cervical motion tenderness, Uterine tenderness, OR Adnexal tenderness. * **Most Common Cause:** *Chlamydia trachomatis* (most common overall) and *Neisseria gonorrhoeae*. * **Gold Standard Diagnosis:** Laparoscopy (shows tubal edema and erythema). * **Definitive Diagnosis:** Endometrial biopsy (endometritis) or Imaging (transvaginal ultrasound showing fluid-filled tubes). * **Fitz-Hugh-Curtis Syndrome:** A complication of PID involving perihepatitis ("violin-string" adhesions).

Question 245: A 39-year-old woman, para 3 live 3, complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus of around 12 weeks pregnant size, with no adnexal tenderness. Results of endometrial biopsy are normal. What is the most likely diagnosis?

A. Endometriosis
B. Endometritis
C. Adenomyosis (Correct Answer)
D. Uterine sarcoma

Explanation: ### Explanation **Correct Answer: C. Adenomyosis** **Why it is correct:** Adenomyosis is defined as the presence of ectopic endometrial glands and stroma within the myometrium. The classic clinical triad for adenomyosis is **multiparous women** (usually 35–50 years old) presenting with **progressive secondary dysmenorrhea** and **menorrhagia**. On physical examination, the hallmark finding is a **diffusely enlarged, "globular," and tender uterus**, typically not exceeding 12–14 weeks in size. The tenderness is often most prominent during the premenstrual phase. The diagnosis is clinical, supported by MRI or Transvaginal Ultrasound (showing "venetian blind" shadowing or asymmetrical myometrial thickening), and confirmed by histopathology. **Why the other options are incorrect:** * **A. Endometriosis:** While it causes secondary dysmenorrhea, the uterus is usually normal in size. Findings typically include fixed retroverted uterus, adnexal masses (endometriomas), or tender nodules in the pouch of Douglas. * **B. Endometritis:** This is an infection of the endometrium, usually presenting with acute pelvic pain, fever, and purulent vaginal discharge, rather than chronic progressive dysmenorrhea. * **D. Uterine Sarcoma:** This is a rare malignancy presenting with rapid uterine growth (often post-menopausal) and irregular bleeding. The uterus would be firm and irregular rather than diffusely globular and tender. **Clinical Pearls for NEET-PG:** * **Adenomyosis vs. Fibroids:** Fibroids cause an *asymmetrically* enlarged, firm, non-tender uterus. Adenomyosis causes a *symmetrically* enlarged, soft, tender uterus. * **Definitive Treatment:** Hysterectomy is the only definitive cure. * **Pathology:** Look for the "Halban’s sign" (tender uterus on examination during menstruation). * **Microscopy:** Endometrial islands must be at least 2.5 mm below the basalis layer to be termed adenomyosis.

Question 246: A 13-year-old girl presents with acute lower abdominal pain. She has a history of cyclical pain for the past six months and has not yet attained menarche. On local genital examination, a tense bulge is seen in the region of the hymen. What is the most probable diagnosis?

A. Mayer-Rokitansky-Küster-Hauser syndrome
B. Testicular feminization syndrome
C. Imperforate hymen (Correct Answer)
D. Asherman's syndrome

Explanation: ### Explanation **Correct Option: C. Imperforate hymen** The clinical presentation of **primary amenorrhea** combined with **cyclical abdominal pain** in an adolescent is a classic hallmark of outflow tract obstruction. In this case, the menstrual blood accumulates in the vagina (**hematocolpos**) because the hymen failed to canalize during embryonic development. The "tense, bluish bulge" at the hymen is the pathognomonic sign, representing the trapped blood visible through the thin hymeneal membrane. Over time, this can progress to hematometra (blood in the uterus) or hematosalpinx (blood in the tubes). **Incorrect Options:** * **A. MRKH Syndrome:** Characterized by congenital absence of the uterus and upper 2/3 of the vagina. While patients have primary amenorrhea, they do **not** experience cyclical pain (as there is no functional endometrium) and there is no bulging membrane on examination. * **B. Testicular Feminization (Androgen Insensitivity Syndrome):** These individuals are genotypically male (46,XY). They have a blind-ending vaginal pouch, absent uterus, and no menstrual cycle; therefore, they do not present with cyclical pain or a bulging hymen. * **D. Asherman’s Syndrome:** This is an acquired condition involving intrauterine adhesions, usually following over-vigorous curettage. It causes secondary amenorrhea in women who previously had periods, not primary amenorrhea in a 13-year-old. **High-Yield Clinical Pearls for NEET-PG:** * **Initial Investigation:** Transabdominal Ultrasound (to visualize hematocolpos/hematometra). * **Treatment of Choice:** **Cruciate incision** or stellate incision of the hymen to drain the accumulated blood. * **Physical Exam Tip:** Rectal examination may reveal a large, tense cystic mass (the distended vagina) anterior to the rectum. * **Differential:** Always differentiate from a **Transverse Vaginal Septum**, where a bulge is usually *absent* on inspection because the obstruction is higher up in the vaginal canal.

Question 247: What is the treatment for partial prolapse in nulliparous women?

A. Shirodkar sling procedure (Correct Answer)
B. Le Fort operation
C. Manchester operation
D. Vaginal hysterectomy with posterior repair

Explanation: **Explanation:** The management of pelvic organ prolapse (POP) in young, nulliparous women focuses on **uterine preservation** and maintaining **reproductive function**. **1. Why Shirodkar Sling is Correct:** In nulliparous women, the primary cause of prolapse is often congenital weakness of the pelvic supports. The **Shirodkar sling procedure** (an abdominal cervicopexy) is the treatment of choice. It involves using a synthetic tape (like Mersilene) to anchor the cervix to the sacral promontory or the anterior surface of the S1 vertebra. This provides strong apical support while preserving the uterus for future childbearing and maintaining vaginal length. **2. Why Other Options are Incorrect:** * **Le Fort Operation:** This is a "colpocleisis" (partial closure of the vagina). It is strictly reserved for elderly, frail women who are no longer sexually active, as it obliterates the vaginal canal. * **Manchester Operation (Fothergill’s):** This involves amputation of the cervix. It is contraindicated in nulliparous women because cervical amputation leads to cervical incompetence, increased risk of mid-trimester abortions, and preterm labor. * **Vaginal Hysterectomy:** This is inappropriate for nulliparous women who desire to retain fertility. It is typically the treatment of choice for post-menopausal women with uterovaginal prolapse. **Clinical Pearls for NEET-PG:** * **Nulliparous Prolapse:** Often associated with conditions like spina bifida, bladder exstrophy, or connective tissue disorders (e.g., Ehlers-Danlos). * **Sling Procedures:** Other abdominal slings include **Khanna’s** (uses fascia lata) and **Purandare’s** (uses rectus sheath). * **Manchester Operation** is best suited for women who have completed their family but wish to retain their uterus (e.g., perimenopausal).

Question 248: Which of the following organisms can cause cervicitis?

A. Pseudomonas
B. Staphylococcus
C. Chlamydia (Correct Answer)
D. Trichomonas

Explanation: **Explanation:** **Cervicitis** is the inflammation of the uterine cervix, primarily categorized into ectocervicitis and endocervicitis. **Why Chlamydia is Correct:** *Chlamydia trachomatis* (Serotypes D-K) is the most common bacterial cause of **mucopurulent endocervicitis**. It is an obligate intracellular pathogen that specifically infects the columnar epithelium of the endocervical canal. Along with *Neisseria gonorrhoeae*, it is a major cause of Sexually Transmitted Infections (STIs) leading to Pelvic Inflammatory Disease (PID), infertility, and ectopic pregnancy. **Analysis of Incorrect Options:** * **A. Pseudomonas:** This is an opportunistic pathogen typically associated with nosocomial infections (UTIs or pneumonia), not primary cervicitis. * **B. Staphylococcus:** While *S. aureus* can be part of the vaginal flora or cause Toxic Shock Syndrome (TSS), it is not a recognized primary cause of infectious cervicitis. * **D. Trichomonas:** *Trichomonas vaginalis* primarily causes **vaginitis** and **ectocervicitis**. While it affects the cervix (producing the classic "Strawberry Cervix" or colpitis macularis), it involves the squamous epithelium of the exocervix rather than the endocervical canal. In the context of standard medical examinations, Chlamydia and Gonorrhea are the definitive answers for "cervicitis" (endocervicitis). **NEET-PG High-Yield Pearls:** 1. **Gold Standard Diagnosis:** Nucleic Acid Amplification Test (NAAT) is the investigation of choice for *Chlamydia*. 2. **Clinical Sign:** "Friable cervix" (bleeding on touch/swab) is a hallmark of infectious cervicitis. 3. **Treatment:** Azithromycin (1g stat) or Doxycycline (100mg BID for 7 days). Always treat the partner to prevent reinfection. 4. **Co-infection:** If *N. gonorrhoeae* is detected, always treat for *Chlamydia* empirically.

Question 249: What is the recommended treatment for a 16-week hydatidiform mole?

A. Hysterectomy
B. Suction evacuation (Correct Answer)
C. Hysterotomy
D. Lower segment caesarean section (LSCS)

Explanation: **Explanation:** The management of a hydatidiform mole (molar pregnancy) focuses on the complete removal of trophoblastic tissue while minimizing the risk of uterine perforation and hemorrhage. **Why Suction Evacuation is the Correct Answer:** Suction evacuation is the **gold standard treatment** for hydatidiform moles, regardless of the uterine size or gestational age. It is preferred because the molar tissue is friable and vascular; suction allows for rapid clearance with minimal trauma to the myometrium. Even at 16 weeks (where the uterus is significantly enlarged), suction curettage is safer and more effective than medical induction or surgical excision. **Why Other Options are Incorrect:** * **Hysterectomy:** This is generally reserved for women who have completed their family or are older (>40 years) to reduce the risk of post-molar gestational trophoblastic neoplasia (GTN). In a standard case, it is not the first-line treatment as it is an invasive major surgery. * **Hysterotomy:** This involves surgically opening the uterus to remove contents. It is contraindicated because it increases the risk of disseminating trophoblastic cells into the bloodstream and peritoneal cavity, potentially leading to metastatic GTN. * **LSCS:** This is a procedure for delivering a viable fetus. In a molar pregnancy, there is no viable fetus (in complete moles), and the procedure carries a high risk of heavy bleeding and future uterine scarring. **High-Yield Clinical Pearls for NEET-PG:** * **Pre-procedure:** Always check blood group and cross-match (risk of hemorrhage) and perform a chest X-ray (to rule out pre-existing lung metastasis). * **Oxytocin:** Should be started **after** the evacuation has begun to prevent the risk of trophoblastic embolization. * **Follow-up:** The most critical post-evacuation step is monitoring **weekly serum β-hCG levels** until three consecutive normal values are obtained, then monthly for 6 months. * **Contraception:** Combined Oral Contraceptive Pills (OCPs) are the preferred method during follow-up; IUCDs are avoided until hCG is undetectable due to the risk of perforation.

Question 250: A 52-year-old perimenopausal woman has had vaginal bleeding for a week. She has no medical problems and takes no medications. Hysteroscopy is performed and there is a single, 2-cm, smooth, soft mass protruding into the endometrial cavity. Biopsies are taken. What is the microscopic examination of this lesion most likely to show?

A. Endocervical glands with squamous metaplasia
B. Endometrial glands resembling stratum basalis (Correct Answer)
C. Papillae with marked cellular atypia
D. Smooth muscle cells in bundles

Explanation: ### Explanation **Diagnosis: Endometrial Polyp** The clinical presentation of a **perimenopausal woman** with abnormal uterine bleeding and a hysteroscopic finding of a **single, smooth, soft mass** protruding into the endometrial cavity is classic for an **endometrial polyp**. **1. Why the Correct Answer is Right:** Endometrial polyps are localized overgrowths of endometrial stroma and glands. Microscopically, they are characterized by **endometrial glands that resemble the stratum basalis** (the deep, non-functional layer of the endometrium). These glands are often cystically dilated and are supported by a stroma containing **thick-walled, prominent blood vessels** and fibrous connective tissue. Unlike the functionalis layer, these glands are often out of phase with the rest of the endometrium and do not shed during menstruation. **2. Why the Incorrect Options are Wrong:** * **Option A (Endocervical glands with squamous metaplasia):** This describes a **cervical polyp** or normal transformation zone changes. While cervical polyps also cause bleeding, the hysteroscopic location (endometrial cavity) confirms an endometrial origin. * **Option C (Papillae with marked cellular atypia):** This is suggestive of **Uterine Serous Carcinoma** or atypical endometrial hyperplasia. While malignancy must be ruled out in perimenopausal bleeding, the "smooth, soft" description of a single mass is more consistent with a benign polyp. * **Option D (Smooth muscle cells in bundles):** This describes a **Leiomyoma (Fibroid)**. A submucosal fibroid would appear as a firm, solid mass on hysteroscopy, rather than a soft, fleshy polyp. **3. Clinical Pearls for NEET-PG:** * **Most common symptom:** Abnormal Uterine Bleeding (AUB). * **Risk Factors:** Obesity, Tamoxifen use (due to its pro-estrogenic effect on the uterus), and Hypertension. * **Gold Standard Investigation:** Hysteroscopy with guided biopsy (allows both visualization and treatment). * **Management:** Polypectomy is recommended in symptomatic patients or postmenopausal women to rule out rare focal malignancy (1–3% risk).

Practice by Chapter

Abnormal Uterine Bleeding

Practice Questions

Endometriosis

Practice Questions

Adenomyosis

Practice Questions

Uterine Fibroids

Practice Questions

Ovarian Cysts

Practice Questions

Pelvic Inflammatory Disease

Practice Questions

Vulvovaginitis

Practice Questions

Pelvic Organ Prolapse

Practice Questions

Vulvar Disorders

Practice Questions

Benign Breast Diseases

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